The Scuba Registry - Individual Diver Registration

Indvidual Diver Registration Form	step 02 of 04
Use the following form to take the first step in protecting your gear. Once you are a member you can edit your profile simply by signing in with the user name and password you are about to create.
* indicates required fields

Promo Code & Referring Source
promo code:	How did you hear about us?

	name of dive buddy/instructor? which dive shop referred you? which website referred you? what trade show did you see us at? which magazine did you see us in? which newspaper did you see us in? what television show did you see us in? which radio station did you hear about us on? In what city was the billboard located? please include referring source:
Login Information
User name*:	(This will be your screen name)
password*: (must be at least 6 characters)	confirm password*: (must be at least 6 characters)


Contact Information
first name*:	last name*:

street address*:
street address2:
city:	country*:
zip/postal*:	Province/State*:	Province/State:
email address*:	phone number:
website address:


Dive History
highest dive level completed*: (i.e: Rescue Diver, Dive Master etc)
Certifying Agency(s): Hint: Hold down the Ctrl button to select multiple agencies
Your dive story:
Most memorable dive:
Scariest dive moment:
Number of Dives:
Dream dive would be where:
Other Hobbies:
Occupation:
add me to the buddy directory*: yes no
email me gear alert messages*: yes no